I'm sorry that I have been away from the blogsphere for so long, but this week has been incredibly busy! I prognosticated that last weekend would be jam-packed with action due to the full moon. It turns out that I am a lousy fortune-teller. My weekend was relatively uneventful. It was the calm before the storm. Forewarning, this post maybe the longest I have written, so get comfy or be prepared to skim a lot.
I awoke later than normal on Monday, planning to go directly to the office. I was quite pleased that I didn't have to make the trek to the hospital, and was planning on a short day in which I could get laundry done. Ah, the best laid plans! Just as I was about to shower, the pager sounded. "Hi, we have Lady#1 here, she's 5-6 cm and posterior (this means high in the pelvis)." So much for not going into the hospital. I gave the standard admission orders, and figured that I had enough time for a shower before heading toward the hospital. Scarcely 10 minutes later, I had just gotten the conditioner halfway out of my hair, when the pager sounded again. Uh, oh. "We need you right now! She's about to deliver." Crap. Scrubs, car keys, frantic 15 minute race to the hospital. I roll into the room. Baby is out. The nurse says, "Sorry, I barely made it to the delivery and I was just at the nurse's station! Even if you hit the pavement when we called the first time, you couldn't have gotten here." Somehow, I didn't feel better about that. The patient was very understanding. She had waited several hours at home in labor because she had no ride to the hospital. I sewed up the laceration she had from having an unassisted, precipitous delivery, and we joked that she would have to move into the hospital prior to her next delivery in order to ensure she wouldn't deliver at home. After everything was repaired, I went back into the nursery to try to rinse the remaining conditioner out of my hair. Somehow, I wasn't too successful and spent the rest of the day looking like one of the chicks from the Robert Palmer video....except much, much fatter, with less (read, NO) makeup. Bad analogy.
Halfway through the morning in the office, the pager sounds again. I'm certain that it is a question related to my morning delivery or a non-stress test. Silly, naive me. "Lady #2 is here, she was here last night? Now she is 4 cm and hurting...What do you want us to do?" They know the answer to this question, but, like me, they like to prolong the inevitable. They are already short-staffed. I admit her and tell them to give her IV pain meds and let her walk. The office morning proceeds smoothly, and right around lunchtime, I am treated to a phone call from Lady #2's mother. I am going to kill my office staff for putting her through. She proceeds with a long, rambling diatribe on how her daughter has been laboring for a whole 24 hours, and how that was way too long, and how she had to be put on "patossium" for all of her labors. (I can only assume that she means pitocin, a synthetic form of oxytocin, which is used to initiate regular contractions, and not some strange new mineral.) Then I get treated to each agonizing detail of each of her deliveries, including food cravings and amount of weight gained before I can finally cut in and tell her that her daughter is contracting every 2-3 minutes without "patossium," she is in early labor, and she is doing just fine. I finish office and head to the hospital, where I break Lady #2's water, (meconium, great) and place internal monitors. She is 5 cm, hurting, and refusing both pain meds and an epidural. This is fine by me, as I like it when women are committed to natural labor (I prefer drugs/epidural for myself, but your body, your labor). Women tend to push better when they have that "primal urge." Unfortunately, the reason Lady #2 is not accepting pain medicine is not because she doesn't want it; it is because her mother has scared the bejeesus out of her that she will be paralyzed from an epidural, and that IV pain medicine will stress the baby. She is young and malleable, and I just keep my big mouth shut. Eventually, deep variable decels herald the baby's imminent arrival. Mom is writhing and rocking now, hysterical with pain. I check and find that she is completely dilated, but baby's presentation is transverse (the head is sideways). She is not pushing effectively because she is in too much pain to focus and stay in control. She refuses a pudendal block. Her exact words, "That big needle is not going in THERE!" The baby is not tolerating the pushing progress all that well, so I put on a vacuum extractor to rotate the head to an anterior presentation (this is much easier to deliver). The patient then decides that this is the moment to push herself away from me (and from the pain as the baby descends) the vacuum pops off. Shit. We coax her back down to the end of the bed, I injected a local anesthetic to try to give her some relief. No luck. The thing about operative deliveries is that the patient still has to push to get the baby out. You cannot drag the kid out by the head alone, it doesn't work that way. I re-apply the vacuum and get the baby to crown, cut an episiotomy, as mom refuses to push any more, and (finally) get the baby out. I reduce the nuchal cord, suction the meconium stained fluid, hand the floppy baby immediately to the nurse, and (after about a gallon of lidocaine) repair the 2nd degree episiotomy. Above me as I sew, Lady #2 and mom are congratulating themselves that she did this "all natural." Never mind that the baby was completely stressed and she wouldn't focus and push the baby out because she was in such pain. Never mind that the baby was floppy with no tone and poor color at delivery. I sew and keep my mouth shut, knowing that sometimes, a little pain relief can be the lesser of evils.
Baby # 3
Earlier, in the office, my nurse tells me that Lady #3 had called and was having a "few contractions." She is desiring to VBAC (vaginal birth after cesarean) so I tell my nurse to advise the patient to proceed to the hospital should the contractions persist. She presented to triage shortly before I delivered Baby #2, smiling and calm. "Surely she can't be in hard labor and look that comfortable," remarks the triage nurse. Wrong. She is 5-6 cm and contracting every minute....with a smile on her face! She is very surprised when we tell her she is going to stay. She gets an epidural right away, gets comfy, and I break her water and place internal monitors to monitor the intensity of her contractions. The danger of attempting a VBAC is uterine rupture (and subsequent fetal and/or maternal death) during labor. Fortunately, this happens only about 2% of the time, and upwards of 75% of woman can have a successful VBAC. Lady #3 is determined, focused, and confident that her body can do this. I regard her with hope and the smallest amount of doubt and fear of the worst outcome in the very back corner of my mind. She progresses normally to the point of pushing, we turn off the epidural to give her more of an urge to push. She pushes and pushes well for over an hour and a half when I notice that the uterine monitor is no longer registering at the proper level. The baby is not distressed, but I am. I check the position of the monitor, confer with the nurse, and worry that the drop in pressure is the sign of an impending uterine rupture. There is no loss of station, there is no fetal distress, mom feels no discomfort, but I am fearful. At last, the baby crowns, and the uterine monitor emerges, completely wrapped around the baby's body. It had been compressed by the weight of the baby as it descended through the canal. I delivered the (large) baby and placed the baby triumphantly on mom's belly. Everyone in the room is crying, including me. The baby is well over eight pounds. She has a 3rd degree laceration, but it is easy to repair. Her old uterine scar is intact, and we have achieved a successful VBAC. I arrive home sometime around 2 am, exhausted, but happy to end the night on a high note.
Lady #4 is a patient that transferred care to me early in her second trimester. I like her, she and her husband are very nice, and I even believe we could possibly hang out socially (if I would hang out with patients, that is). Obviously she feels the same way, as she insists on calling me by my first name. I always introduce myself as Dr. Whoo. I don't really like it when patients call me by my first name, as I always call them Ms. LastName and wish the same respect from them. I feel it keeps the professional boundaries in place. (It also irks me when we get mail addressed to Mr. and Mrs. Whoo from people who know that I am a physician. It's not that I am not a "Mrs." too, but I worked hard for that title, and I want to see it used in a formal manner.) I find that the more highly educated and the very poorly educated are the worst offenders when it comes to the first name basis. I do not correct them. I just grit my teeth and bear it. Despite the first name foible, I do like this patient, and brought her in for induction of labor for post dates. Apparently, her first delivery was horrible and miserable (see Lady #2) and she is expecting the worst. She has a fairly reasonable birthing plan. I encourage her to get her epidural early, break her water, and go into the office. The office is a madhouse on Tuesdays and Thursdays, and I find myself hoping to be called away early. For once, my prayers are answered. I get the call from labor and delivery that my patient is fully dilated, but comfortable with her epidural. I cancel the rest of the day (whoopee!) and zip to the hospital. Once I arrive, she begins to push and pushes for maybe 30 minutes until the baby crowns. I gown, glove, and deliver the baby. It is one of those deliveries that is just as smooth as silk. Controlled head delivery, stretching the perineum, no episiotomy, no tears, easy shoulders, slow body delivery, instantaneous cry, poignant music playing in the background, Daddy crying and cutting the cord and placing baby immediately on Mommy's bare belly. It is beautiful and I am happy, they are happy, and the baby is happy. Life is good, and I get to go home before 6 pm.
Lady #5 is a character in the true sense of the word. She is an immigrant from a South American country. Her father is an OB in her country, and I am going to be the first person besides her father to deliver one of her children. She is melodramatic, impatient, and a princess, but she complains with a smile. She is strong-willed, and highly annoyed that I will not take the baby before 1 week prior to her due date because she is "so fat she can't stand it." She weighs in the ballpark of 130-140 pounds at full term, and my lip is bleeding from being bitten so hard in the last few days. She is a third time repeat C-section, and is going to have her tubes tied, as well. She is a scheduled surgery, my second of four (scheduled) surgeries for the day. Her C-section is difficult. She has a lot of scar tissue from her previous surgeries that takes a lot of time to dissect. Her skin incision is not only tiny, but is also just one big cheloid (this scar tissue is not very pliable) that she would like removed. I can barely get the baby's head through the tiny skin incision, but I know she will be most displeased if I cut her one millimeter more than her previous incision. The baby is delivered and does well. I repair the uterus and tie and cut her tubes. She asks several times throughout the surgery if I have, indeed, cut and tied them. Once everything is repaired, I set about removing her old scar. She is so thin that she doesn't have a lot of extra skin or fat in this area, which makes removing the old scar rather difficult. I do my level best, but the incision ends up with a slight curve to it on the right side and I need to close it with both suture and staples to be certain that the tissue comes together correctly. It doesn't look perfect and I beat myself up. I know that she won't be thrilled, but surprisingly she is ok with it. We'll see how she feels when it heals completely.
Baby #6 was really supposed to be Baby #5. I brought Lady #6 in for induction the same day that I brought in Lady # 4. Her baby was consistently measuring above the 90th percentile for growth (LGA - large for gestational age) and her pregnancy was complicated by borderline gestational diabetes, elevated blood pressure, maternal obesity, and the fact that she works in the hospital. Physicians, physician's wives, nurses, and hospital personnel always seem to have complicated pregnancies, labors, and deliveries. I wish I knew why. We started her induction on Monday evening with a cervical ripening agent, followed by misoprostol, then by pitocin all day long on Tuesday. She never dilated more than 1 cm, so I rested her overnight on Tuesday evening, let her eat, and restarted another cervical ripening agent at midnight. When I arrived at the hospital early Wednesday morning (around 7 am), she was 2 cm dilated, and the baby had descended enough that I could break her water and place monitors. I started the pitocin again and went about my scheduled surgeries. I returned after the completion of all four scheduled surgeries at around 3pm to find her hurting, her epidural not working, and only dilated 4-5 cm, despite contracting well for every 1-2 minutes. Not very much progress in 8 hours. I gave her one more hour and re-checked again. She was still 4-5 cm and the baby was very high in the pelvis. At this point, she was exhausted and just ready to have a baby, so we proceed to C-section for failure to progress. The surgery was uneventful, and the so-called macrosomic baby was just a smidge over 7 pounds. Ah, the accuracy of third trimester ultrasound. I beat myself up for the remainder of the surgery for inducing her for an LGA baby when she didn't have one. There was no way that I could know, based on the info that I had, but I berated anyway.
Baby # 7
I induced Lady #7 for mild pre-ecclampsia and gestational diabetes class A2 (medicine controlled) . Funny, she works in the hospital too. The baby was also measuring greater than 90% (should have known better than to trust those darned US techs) but this was a secondary consideration to her blood pressures and urine proteins that were slowly creeping upward. She was already 2 cm dilated, so I broke water right away and started pitocin. She weighs over 300 pounds, so it was difficult to monitor her externally. Internal monitors were placed, and I proceeded with my surgery day. As I was finishing the C-section of Lady #6, the nurse called with a 3 minute fetal decel to the 60s. It had returned to baseline, but she had (correctly) stopped the pitocin. I headed immediately to the patient's room to check on her once I completed surgery. The baby had recovered, the fetal heart tracing was good, and when I checked, she was a good 5 cm dilated. She was very uncomfortable, and IV pain meds were not cutting it. She decided on an epidural, and I told the nurse to hold off re-starting the pitocin until the epidural was in to give Mom a break and allow the baby to recover from the deceleration. All looked well, and she got nice and comfy after her epidural. Time to restart the pit, as her contractions were non-existent at this point. The baby did not like this idea at all. As the pitocin went on, the baby misbehaved. It had repetitive decelerations (dropping of the heart rate) and lost variability (a sign of impending acidosis - bad stuff, fetal distress). Something wasn't quite right about the contraction pattern, either. She was camel-humping, or doubling her contractions, a usual sign of posterior presentation. When a baby is occiput posterior (OP), it is looking up toward the sky instead of down to the floor (occiput anterior or OA). OA presentation is the most common delivery presentation, and it is also the easiest to descend through the pelvis. At any rate, the contraction pattern was, for a lack of a better word, shit, and the baby looked like crap, and Mom was only dilated 6 cm, too long to wait. It was off to the surgical suite once again. This time, when I opened the uterus, two eyes blinked up at me. The baby was indeed OP. This (also supposedly macrosomic, 8 plus pound) baby was barely over 7 and a half pounds, and I curse the US techs once again. The surgery was difficult because of the patient's size, but it went well, and I left the hospital around 10pm. As exhausted as I was from the events of the day, I had to stay up and watch the Tivo'ed finale of SYTYCD. Yay for Benji, the year of the everyman continues! (I would have been happy either way, but I felt a little sad for cute little Travis.) They all will do well, and I am sad because it is all over.
I am getting tired all over again just typing this, and I'm quite sure that I lost most readers around Baby #2, but it is fun to write about the events of the week, so if you're still reading, last one! Lady #8 was an induction of labor for post dates and elevated blood pressure. I dreaded inducing her, because from her first check in the office, I was pretty sure she would end up as a C-section for a narrow pelvis. Her pressures were creeping up around 150-160s/80s, and her poor feet were so swollen they looked like Fred Flintstone feet! I brought her in for cervical ripening overnight on Wednesday night, and by Thursday morning she was already 3 cm dilated. A good place to start! I broke water, placed internals, and headed to the office. Hoping, once again, to be given a reprieve from my ridiculously long patient schedule for the day. That prayer was once again answered, as the nurse called around 3 pm to say that she was already 9 cm dilated. Not bad for a first time mom! Hopefully I was wrong about her pelvis! I cancelled patients for the rest of the afternoon, somewhat begrudgingly, knowing what it would mean for clinic days to come, and once again sped off to the hospital. By the time I arrived, she was completely dilated and really feeling the urge to push. Usually, I am very happy about all of this, but when I checked her, the baby was still relatively high in the pelvis, and developing some caput (swelling at the top of the head). I talked my fears down, and allowed her to start pushing. The. Baby. Did. NOT. Like. Pushing. AT. ALL. It dipped it's heart rate into the 60s and threatened to stay there. It had late appearing decels (a sign of distress). It dropped it's baseline from 130s to the 110s, and it stayed nice and high in the pelvis. (I envisioned the kid with its arms and legs planted widely, pushing itself away from the vagina.) When the patient did not push, the baby did well, so we tried to have her "labor down" where the uterus pushes the baby through instead of active maternal pushing...in order to conserve Mom's energy and to give the baby a break. No such luck. She couldn't fight the urge to push, and baby couldn't tolerate the pushing. It was too high to place forceps or a vacuum, and as the baby took another dip down into the 60s I called for a stat C-Section. A race to the OR. Catheter. Prep. Cut, rip, and tear. The good news? I went from skin incision to baby in under a minute, and after a rough first minute (Apgar of 5), the baby started squawking and perked up nicely. The bad news? A uterine incision extension into the cervix. The baby was so low in the pelvis, and the lower uterine segment was so thin at the time of incision, that it simply ripped like paper when the baby was delivered. I fixed the laceration and ligated a vessel that appeared to be the cervical branch of the uterine artery. A common complication of an extension like this is bladder injury, but I inspected the bladder thoroughly and it appeared intact. I had to re-enforce the incision with a few layers of suture, and finally got it to stop oozing and bleeding. The rest of the surgery proceeded well. I went to speak to the family after the surgery, detailing all of the bad things that could happen in the next 24 hours (bleeding, occult bladder injury, infection, etc.) This is kind of a voodoo for me, I feel as if I prepare people for the very worst, the outcome will be good. I'll let you know if this is a good practice or not once she heals, but so far, so good. They were all relieved and happy, and thanked me (warm fuzzies). The patient said the surgery was way easier and nicer than having to push the baby out, anyway. (Go figure!) SO, all is well that ends well! With that, so ends my exhausting week and even more exhausting post. This next week, I am on vacation! Yip, yip, yippeeeee!